How did woman die in nursing home shower?

The facts surrounding Mary Ware's death can only be found by navigating a complicated trail through a government information system that is supposed to help consumers.

By BARBARA PETERS SMITH

Mary Ware may have already been dying when nursing home workers forced her to take a shower and one of them sprayed water in her face. But the cause of her death will never be known.

Shortly after the 96-year-old Bradenton woman, terminally ill and mentally impaired, became unconscious during a shower Aug. 25 at Springwood Care and Rehabilitation Center in north Sarasota, paramedics pronounced her dead. Her body was moved to Westside Funeral Home in Palmetto and embalmed before a medical examiner could determine the cause of her death.

On Aug. 28 the Sarasota County Sheriff's Office closed the case, finding no evidence of foul play.

But skilled nursing facilities are among the most highly regulated and closely watched businesses in America, with the government filing regular inspection reports available to the public. State regulators classified the fatal shower episode as abuse and prohibited Springwood from taking new patients for 14 days.

The company that in December 2012 bought Springwood, a 117-bed for-profit facility formerly owned by Sun Healthcare Group, has appealed the state's findings.

"We are waiting for the appeal hearing to be scheduled, so we are not able to comment further at this time," said a statement from Jeanne Moore of Genesis, one of the nation's largest long-term care chains. "However, in an abundance of caution, the center took steps to re-educate staff and assess all residents."

Springwood's direct-care staffers received extra training in how to bathe residents safely. Later visits by the state Agency for Health Care Administration found the home to be in compliance with safety rules, but a Jan. 11 visit found multiple violations — ranging from the rough handling of a resident witnessed in the dining room, to a faulty thermometer that apparently led to cool showers for residents. A February report said these deficiencies were corrected.

The circumstances of Ware's death earned Springwood a place on Florida's little-known Nursing Home Watch List, a roster that includes 20 percent of the state's skilled nursing facilities and is designed to assist consumers in evaluating the quality of nursing home care.

But it takes dogged research to sift through the myriad reports and ratings systems compiled by state and federal regulators. And even then, getting a straightforward answer on incidents and problems at facilities is not easy.

The facts surrounding Ware's death at Springwood can only be found by navigating a complicated trail through a government information system that is supposed to help consumers evaluate long-term care facilities.

The incident demonstrates the difficulty of providing daily care to a growing number of very elderly, fragile residents with multiple diseases, especially at a time of aggressive cost-cutting in the elder care industry.

And it highlights an emerging debate over a key element of long-term care — whether facilities should force residents to take showers.

Moreover, it demonstrates the difficulty of providing daily care to a growing number of very elderly, fragile residents with multiple diseases, especially at a time of aggressive cost-cutting in the elder care industry.

Philip D. Sloane, a medical professor at the University of North Carolina, cautioned against judging a facility based on one questionable death.

Sloane, who has helped lead a national movement against forcing nursing home residents to take showers against their will, said long-term care facilities are "full of well-intentioned, hard-working people who toil under very difficult circumstances, often with inadequate training and resources, in service of a population that under the best care is still going to have bad things happen."

Screams in the shower

Reports reveal that Ware — like many nursing home residents with cognitive impairment — was not an easy patient, especially in the shower. Even in her bed she would scream, according to nurses' notes, and could sometimes be silenced by a combination of morphine and a soothing back rub.

Ware had terminal colon cancer, and was receiving palliative treatment — comfort, not a cure. She had been a resident of Springwood since July 20, but at the time of her death she had been back in the facility for just two days, after spending a week for mental evaluation at Sarasota Memorial Hospital.

She had been placed under "protective custody" at the hospital, a step taken when a patient is deemed capable of harming herself or others.

The primary facts of her Aug. 25 death are not in dispute, according to state and county investigation reports:

• Ware had been moaning and screaming the night before she was taken from her bed at about 11 a.m. by two certified nursing assistants, Alexis Barnes and Ciera Ray, who later said her strong odor made the shower necessary.

• Once in the water, Ware fought back vigorously. Her "screaming and hollering" caught the attention of a third CNA, Latoshia Bellamy. She came to help Barnes and Ray, holding the shower nozzle that Ware was trying to grab away from them.

• Barnes noticed a whitish or tan substance coming from Ware's mouth. Bellamy sprayed water in her face, even after Barnes told her to stop, because Ware had trouble swallowing and was on a diet of thickened liquids. Barnes and Ray told investigators that they heard Ware's coughs, and a gurgling noise that sounded like choking. They said Bellamy was laughing, saying, "Come on, Ms. Mary," as she washed the struggling woman's face.

• At about 11:50 a.m., according to a nurse's note cited in the state report, the aides called a nurse to the shower, where Ware was unresponsive with a faint pulse. The nurse told them to carry Ware to her bed, and CPR was administered. Paramedics arrived about 15 minutes later, and pronounced Ware dead.

Death is a given in nursing homes, and few of those in in such facilities — under 1 percent, according to several studies — result in an autopsy. Only about 12 percent are investigated at any level.

But Springwood's response to the death concerned state inspectors. They found that the facility's failure to prevent abuse and its lack of immediate and thorough retraining of its staff amounted to "immediate jeopardy," leaving other residents in potential danger.

When inspectors questioned staff members four days after Ware died about their latest instructions for showering, one employee still had an impression that it was acceptable to spray a resident's face to wash away soap or mucous.

One of the unanswered questions about Ware's death is whether the substance on her face was soap, as one of the aides thought, or "foaming at the mouth" — a symptom sometimes present at death when the lungs are filled with fluid, as noted in Sheriff's Det. Kimberly McGath's report.

The funeral director was not told until the night Ware died that her case was under investigation; by then her lungs and other vital organs had been removed for embalming. This made it impossible to determine a cause of death.

The watch list

Florida maintains an ongoing register of nursing homes that have raised concerns in the past 30 months.

But the watch list is difficult to find online, even for people who know to look for it.

And the national website maintained by Medicare, called Nursing Home Compare, is ambiguous. For example, it doesn't mention of any trouble at Springwood — only a mystifying single star in the "health inspections" category.

Of 140 facilities on Florida's Nursing Home Watch List, nine are in Southwest Florida — about 18 percent of the region's 49 nursing homes.

Brian Lee, director of Families for Better Care, an advocacy group for the elderly based in Tallahassee, said state regulators should be commended for maintaining such a list.

But he says regulators could do a better job of promoting the information for consumers. The agency's website is difficult to navigate for people outside the industry. This makes it hard for residents' family members and friends to hold nursing home operators accountable and push them to improve.

"I'm so glad they're putting out the information, but it's stuck in somebody's closet," Lee said. "This is the kind of information that people want, but folks aren't going to go through 20 clicks on the website to find it."

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